Provider Demographics
NPI:1891167912
Name:HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
Entity type:Organization
Organization Name:HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENEE/OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CLARENCE
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-456-3742
Mailing Address - Street 1:11775 WALNUT ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040
Mailing Address - Country:US
Mailing Address - Phone:619-270-4484
Mailing Address - Fax:
Practice Address - Street 1:11775 WALNUT RD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-5624
Practice Address - Country:US
Practice Address - Phone:619-270-4484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374603669320800000X, 3104A0630X, 311ZA0620X, 310400000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility